Bill > S796

Introduced Session

This bill provides for expanded health insurance coverage for treatment of mental and nervous disorders and alcoholism and other substance-use disorders. Mental Health Coverage: The bill expands the mental health coverage provisions of P.L.1999, c.106 and P.L.1999, c.441 to require that if a health insurer provides coverage for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (currently, the DSM-IV) and is not a biologically-based mental illness, the insurer shall provide coverage for that disorder under the same terms and conditions as provided for any other sickness under the policy. Health insurers include hospital, medical and health service corporations, individual and small employer and large group commercial health insurers and health maintenance organizations. These provisions would also apply to the State Health Benefits Program. The mental health "parity" coverage requirement is currently limited to biologically-based mental illness, which is defined as a "mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness including, but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, and pervasive developmental disorder or autism." The DSM-IV is published by the American Psychiatric Association and is the principal diagnostic reference used by mental health professionals in the United States. The DSM-IV includes a broader range of mental and nervous disorders than biologically-based mental illnesses. The bill clarifies the definition of "same terms and conditions," and makes it consistent with the definition of that term as provided in the sections of the bill concerning benefits for treatment of alcoholism and substance-use disorders. The revised definition provides that an insurer cannot apply different copayments, deductibles or benefit limits, "including day or visit limits or annual or lifetime dollar limits," to mental health benefits than the insurer applies to other medical or surgical benefits. The provisions of P.L.1999, c.106 and P.L.1999, c.441, which provide that the mental health parity requirements in those laws shall not be construed to change the manner in which the carrier determines whether a mental health care services meets the medical necessity standard as established by the carrier, or which providers shall be entitled to reimbursement for providing services under the policy or contract, shall also apply to the expanded mental health coverage in this bill. Coverage for Treatment of Alcoholism and Other Substance-use Disorders: The bill also requires health insurers, as well as the State Health Benefits Program, to provide coverage for treatment of alcoholism and other substance-use disorders under the same terms and conditions as for other diseases or illnesses. Specifically, the bill revises the existing statutory requirement to provide coverage for treatment of alcoholism that applies to hospital, medical and health service corporations, commercial health insurers and the State Health Benefits Program (but currently not to individual and small employer health benefits plans and health maintenance organizations), to add coverage for treatment of other substance-use disorders and to specify the types of benefits that must be covered. The bill extends the requirement to provide coverage for treatment of alcoholism to those health insurers which are not already mandated by State law to provide such coverage, and includes the requirement to provide coverage for treatment of other substance-use disorders. The bill provides that: · Benefits shall be provided when the treatment is ordered by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the DSM (currently, the DSM-IV) and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. · "Treatment of alcoholism and other substance-use disorders" is defined to include, but not be limited to, any of the following items or services provided for treatment of alcoholism and other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group, and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders. · "Same terms and conditions" is defined to mean that the insurer cannot apply different copayments, deductibles or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorders treatment services than those applied to other medical or surgical expense benefits. · All health insurance contracts or policies shall provide the following benefits: -- inpatient or outpatient care in a licensed health care facility; -- treatment at a State-licensed detoxification facility; -- participation as an inpatient at a State-licensed residential facility or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and -- treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional. · Treatment at any facility shall not preclude further or additional treatment at any other eligible facility if the benefit days used do not exceed the total number of benefit days provided for any other disease or illness under the contract or policy. · The provisions of the bill shall not be construed to: -- prohibit an insurer from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the insurer shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate; and -- change the manner in which the insurer determines which health care providers shall be entitled to reimbursement for providing treatment services under the policy or contract. The bill takes effect on the 90th day after the date of enactment and will apply to health insurance contracts and policies issued or renewed on or after that date.

AI Summary

Committee Categories

Barbara Buono (D)*,  Joe Vitale (D)*,  Robert Gordon (D),  Linda Greenstein (D),  Raymond Lesniak (D),  Nicholas Sacco (D),  Bob Singer (R),  Loretta Weinberg (D), 

Introduced in the Senate, Referred to Senate Health, Human Services and Senior Citizens Committee (on 01/12/2010)